Fatty Liver – NASH (Non-Alcoholic Steato-Hepatitis)

What is fatty Liver?

Fatty liver means there is excess deposition of fat in your liver cells. In medical terms, it is called NAFLD (Non-Alcoholic Fatty Liver Disease), which simply means increased deposition of fat in your liver. Sometimes, this condition can lead to inflammation of the liver cells, which is called NASH (Non-Alcoholic Steato-Hepatitis). Often, you don’t have any symptoms due to this condition. However, in some cases it can lead to cirrhosis of the liver, which is a very serious disease that can be fatal.

In most patients, NAFLD/NASH results from abnormal fat metabolism in the liver due to underlying insulin resistance. Obesity and in particular abdominal obesity seems to play a central role in causing NAFLD/NASH. Insulin resistance in fat cells leads to increased breakdown of fat, which causes an increased flux of free fatty acids into the liver. High insulin level, which is present in these patients with insulin resistance, promotes increased synthesis of fat from free fatty acids in the liver. As a result, there is an increased accumulation of fat in liver cells.

In addition, oxidative stress, which is common in the presence of insulin resistance, can initiate cell death and scarring inside the liver. Therefore, in any individual with clinical features of insulin resistance syndrome and an abnormal liver function test, NASH should be on top of the list of possible diagnosis.

How to Diagnose Fatty Liver – NASH (Non-Alcoholic Steato-Hepatitis)

There are no established standards for screening with imaging studies for NAFLD/NASH. Ultrasound can detect moderate to severe fat accumulation in liver, but fails to detect fatty liver if fat accumulation is less than 18 %. Ultrasound of the liver can be difficult in these patients who are often obese. Also, it cannot distinguish between simple fatty liver (NAFLD) and NASH. In the same way, a CT scan can diagnose moderate to severe fat accumulation in the liver, but the scan can be normal in mild cases.

A new technology called MR spectroscopy (Magnetic Resonance Spectroscopy) appears to be a promising imaging modality, but is available at only a few academic institutions and is expensive. Liver biopsy is supposedly the gold-standard method, but it is invasive, costly and impractical considering the vast number of patients afflicted with NAFLD. Even when liver biopsy is performed, a single core biopsy is of lower diagnostic yield compared to multiple core biopsies.

Criteria for the diagnosis of NASH (Non-Alcoholic Steato-Hepatitis)

In patients with Insulin Resistance Syndrome, we decided to use the following clinical parameters to identify patients with NASH.

Presence of at least 2 of the features of Insulin Resistance Syndrome.

Elevated ALT more than 45 U/L

Use of alcohol limited to no more than 2 drinks (about 20 g) per day.

Negative serology for Hepatitis A, B, and C .

Absence of a drug known to cause liver injury.

ALT (alanine aminotransferase), AST (aspartate aminotransferase), bilirubin, and albumin are blood tests for liver function, and are included in most blood chemistry panels. Elevation in ALT and AST is usually the first indication of liver disease including fatty liver. In more advanced cases of liver disease, serum bilirubin gets elevated, and serum albumin goes down.

The most common causes for abnormal liver function include fatty liver, drugs, alcoholism, and hepatitis. Your physician needs to carefully look into these common causes for abnormal liver function.

Treatment Of Fatty Liver (NAFLD and NASH)

Treatment of NASH is in the rudimentary stages. I believe that treatment of NASH should focus on treating its cause, insulin resistance, which requires a comprehensive approach. Insulin resistance is caused by five factors: genetics, aging, abdominal obesity, sedentary life-style and stress. Therefore, I utilize my 5-step approach, described earlier, to treat insulin resistance in my Type 2 diabetic patients with fatty liver. With this approach, I have seen good results in my patients with fatty liver disease.

In a placebo-controlled study (1), Actos (pioglitazone) was shown to be effective and safe in treating biopsy-proven NASH patients who also had pre-diabetes or Type 2 diabetes. Metformin has been studied mostly in small uncontrolled trials. In one small study (2), researchers noticed some beneficial effects of metformin on fatty liver disease.